Lisfranc arthrodesis is commonly used as a treatment modality for painful tarsometatarsal joint arthritis; deformity correction, such as metatarsus adductus and management of Charcot neuroarthropathy deformities; and for management for acute osseous and ligamentous injuries of the midfoot. Once the surgeon has decided to use arthrodesis for management of tarsometatarsal joint pathology, regardless of the condition being treated, the ability to manage those patients who go on to nonunion or other complications and require revision surgery is paramount.
Nonunion rates in Lisfranc arthrodesis have been reported between 6.7% and 11.4%.1,2 Although not all of these are symptomatic and warrant revision surgery, those that do can present many challenges including patient medical management, hardware removal, surgical planning, considering grafting options, hardware selection, and placement of revision hardware in a small anatomical region with limited bone stock and often limited soft tissue envelope.
There are limited studies evaluating Lisfranc revision arthrodesis, although information can be borrowed from other foot and ankle locations. One study by Grambart and Reese focusing on Lisfranc revision evaluated the effectiveness of a trephine technique on revision tarsometatarsal joint arthrodesis. In this technique, trephines were utilized to prepare the joints with autogenous graft harvested from the calcaneus.3 Overall revision techniques include trephine techniques in other foot and ankle locations as well; use of autogenous and allogenic bone graft, bone marrow aspirate, and biologics have been well described in the literature for use as adjuncts in the surgical management of nonunions. General revision principles cannot be ignored as well, including patient evaluation, such as addressing comorbid conditions that may affect outcomes; hardware selection; identification and management/eradication of infection; and patient factors including compliance, social setting, and support system.
Indications for revision Lisfranc arthrodesis include painful nonunion, malreduction/malunion, painful hardware, infection, and wound healing complications. Nonsurgical management of these complications should also be exhausted when possible to limit the need for additional surgery. These would include nonsurgical management of infection when appropriate, use of external bone stimulators, and extended immobilization and non-weight-bearing.
Contraindications include nonsymptomatic nonunions or hardware failures not resulting in limitations of activity, increased pain, or skin complications. Patients who are poor surgical candidates should be more closely evaluated, and potential contraindications should additionally include peripheral arterial disease, uncontrolled diabetes, peripheral neuropathy, poor nutritional status, untreated infection, and noncompliance.
When evaluating the need for revision procedure, it is important to thoroughly consider any factors that may have contributed to the previous outcome, as well as any modifiable factors moving forward. These can be patient dependent and physician dependent.
In diagnosing nonunion and the need for revision Lisfranc arthrodesis, plain radiographs should be the first imaging utilized. If additional evaluation is needed or if plain radiographs are unclear in regards to healing across the arthrodesis sites, computed tomography (CT) and magnetic resonance imaging (MRI) can be beneficial. Hardware artifact is a potential concern using both of these imaging modalities, and the authors have found CT imaging to be more useful when evaluating for osseous healing. MRI can also be beneficial, however, when evaluating for osteomyelitis around the retained hardware if this is of concern based on the patient’s other workup. Advanced imaging allows for better evaluation of the osseous structures as well, allowing for better evaluation of possible areas of cyst formation, broken hardware, and surgical planning. Given that several joints are also typically involved in tarsometatarsal joint arthrodesis procedures, it is possible that not all joints are in need of revision arthrodesis and therefore will not need to be addressed during revision surgery.
Diabetic patients present with their own set of considerations, including effects on peripheral vascular supply, short- and long-term glucose control, and neuropathy. Adequate blood glucose control is important when evaluating patients with a history of diabetes. Several studies have shown impaired healing, increased rates of wound complications, increased infection rates, and higher rates of bone healing complications in patients with poorly controlled diabetes. Domek et al found that patients with hemoglobin A1c >6.29% had significantly higher rates of complication compared with those with hemoglobin A1c <6.11%. They additionally found that, for each 1% increase in hemoglobin A1c, there was a 5% increase in the complication rate for foot and ankle surgery.9 Underwood et al found hemoglobin A1c >8% to be associated with higher rates of complication in noncardiac surgery.10 This has also been reported in foot and ankle surgery with Wukich et al with reported increased rates of surgical site infections in surgical patients with hemoglobin A1c >8%.11 Hemoglobin A1c >7% has also been shown to increase rates of nonunion, delayed union, and malunion in foot and ankle surgery.12 Perioperative glucose control should also be evaluated, with levels >200 mg/dL shown to be associated with an increased risk of surgical site infection, warranting close monitoring immediately preoperatively and postoperatively.13
There are conflicting reports in the literature regarding whether tobacco use is associated with an increased risk of complications in foot and ankle surgery. In a review by Kim and Patel, they did, however, identify arthrodesis procedures, open reduction internal fixation, and plastic surgery procedures in the foot and ankle to be associated with negative outcomes in smokers.14 Given evidence that smoking may affect arthrodesis, even if inconsistently found in studies, it is worth discussing smoking cessation and risks of nonunion with patients, particularly those undergoing revision arthrodesis, such as in the Lisfranc complex. Testing for tobacco use is readily available and typically consists of nicotine and its metabolite cotinine and can be used to assess for smoking status in patients prior to revision procedures.
Vascular status also needs to be considered as a potential contributing factor when presented with the need for revision Lisfranc arthrodesis. Patients with diminished arterial supply are at risk of healing complications following foot and ankle surgery. Noninvasive arterial testing should be conducted in patients if there are any physical examination or history findings concerning for possible arterial disease. This testing can be particularly important in diabetic patients who are at increased risk of diminished arterial perarthrodesis even in the setting of palpable pulses. Vascular surgery referrals should be made for appropriate further workup and intervention if testing is abnormal prior to proceeding with revision procedures.
Infection is critical to evaluate for in the setting of nonunion or wound healing complications. Imaging, clinical presentation, and laboratory values should all be taken together when evaluating for infection. From a laboratory standpoint, complete blood count, basic metabolic panel, C-reactive protein, and erythrocyte sedimentation rate should all be obtained. C-reactive protein and erythrocyte sedimentation rate are well reported in the literature for work up of suspected osteomyelitis, with a C-reactive protein >3.2 mg/dL associated with wounds deeper than 3 mm being reported.15 Erythrocyte sedimentation rate has various reported cutoff values, with 70 mm/h frequently used.16 If infection as a cause of nonunion is successfully ruled out, single-stage revision can typically be undertaken. In the setting of infection, staged procedure is often required to allow for removal of existing hardware, obtaining of appropriate culture and pathology specimens, and appropriate, often long-term, intravenous antibiotic therapy. Frozen sections can also be useful when evaluating for infection during a revision procedure.17
Finally, patient social factors should also be given weight when evaluating an individual for revision arthrodesis. These include the patient’s ability to maintain non-weight-bearing, which may be influenced by home environment, overall physical status, their support system, willingness to undergo revision procedure, prior adherence to postoperative protocols, and willingness/ability to participate in regimens such as nutritional optimization, glucose control, and smoking cessation.
Bone graft should be utilized in the setting of revision arthrodesis. Ultimately its source and type are often up to the surgeon’s preference, comfort in harvesting, availability, and cost. It is the authors’ preference to utilize autograft for revision procedures. This can be easily harvested from the distal tibia or calcaneus and supplemented with other materials if a larger volume of graft is needed. Both anatomical locations have been described in the literature. For the anterior tibia several studies have shown its safety and ability to provide adequate amounts of graft including a study by Danziger et al, which showed no complications, and a study by Chou et al, which found a 4% rate of stress fractures, all of which healed with immobilization.18,19 For calcaneal autograft, several studies have shown its safety and effectiveness as well. Law et al retrospectively studied 966 patients, finding 1 stress fracture and 14 other complications including heel pain, graft site tenderness, sural neuritis, and hypertrophic scarring. They harvested an average of 5 to 10 mL of material.20 Cross et al had similar results evaluating 247 graft sites with a 2.43% complication rate including 5 patients with sural neuritis and 1 with hypertrophic scar formation.21 Both sites allow for harvesting of adequate amounts of autograft material for most revision arthrodesis procedures of the Lisfranc complex while avoiding the complications associated with autogenous iliac crest harvesting.
After preoperative workup and surgical planning as above, revision surgery is undertaken. This is typically performed with either monitored anesthesia care sedation and regional block or general anesthesia. The patient is placed in a supine position with bump under the ipsilateral hip. Calf or thigh tourniquet is utilized. After the patient is prepped, it is our preference to typically use a 2-incision approach. Although traditionally the incision is described between the first and second and third and fourth metatarsals, our preference is to use an incision between the second and third metatarsals and then measure medially 4 cm for the placement of a second incision over the dorsal or dorsomedial aspect of the first metatarsocuneiform joint. This allows for excellent visualization and access to the medial and central rays typically undergoing arthrodesis in the Lisfranc complex, while allowing for avoidance of the dorsal neurovascular bundle.
Dissection is carried out to the level of bone and then the dorsal joints are cleared of any soft tissue attachments. The dissected areas can be joined under a skin bridge containing the neurovascular bundle connecting the medial and lateral incisions as needed for additional access and joint preparation. All joints are prepped to allow for appropriate reduction prior to reduction. The authors have found it useful to position Hintermann-type distractors for joint preparation using curettes. Placement of the retractor for the second and third metatarsocuneiform joints is done with Kirschner wires in the second metatarsal and lateral cuneiform or the third metatarsal and medial cuneiform. This allows for preparation of both joint areas at the same time while reducing the need for additional wire holes in the limited bone stock. After preparation of joints with curettes and fenestration of the arthrodesis sites with drilling, the autogenous bone graft is harvested. For tibial autograft, this is harvested using an incision between the tibialis anterior and extensor hallucis longus tendons along the anterior aspect of the distal tibia. Sharp and blunt dissection is carried out down to the tibia and trephine used to create a cortical window. Curettes are then utilized to harvest graft and the void is typically filled with bone chips or demineralized bone matrix. The cortical window removed with the trephine is then replaced. A similar technique is utilized along the lateral aspect of the calcaneus to harvest autograft from that location.
Following the harvesting of autogenous bone graft, attention is redirected to the arthrodesis sites. The harvested autograft is placed at the sites and supplemented with allograft or demineralized bone matrix if additional volume is needed or bone voids are present. Temporary fixation can be achieved with Kirschner wires as needed. As the authors typically utilize plate and screw constructs for initial arthrodesis procedures, staples are typically used in a revision setting. This allows for strong and adequate fixation while avoiding areas of bone used in the previous fixation. Regardless of the revision fixation method utilized, it is important to plan ahead with placing new fixation given the limited bone stock and small soft tissue envelope available in this area. If multiple joints are being revised, the second is typically fixated first followed by the third and first. Intraoperative C-arm fluoroscopy is utilized to ensure reduction and allow for appropriate hardware placement. After the final fixation is verified under C-arm fluoroscopy, the incisions are irrigated and closed in a layered fashion alternating between the medial and lateral incisions to allow for adequate soft tissue closure. The incisions are then dressed and the patient is placed into a well-padded posterior and sugar tong splint.
On physical examination the left foot had a surgical scar over the first and third interspaces that were well healed. There was a moderate hallux valgus deformity with enlargement and prominence of the first metatarsal head. She had tenderness over the first and second tarsometatarsal joints and guarding through the Lisfranc complex. There was no gross instability, but physical examination was somewhat limited due to tenderness. There was also crepitation noted with examination of the midfoot. Radiographs revealed internal fixation consistent with a Lisfranc injury and repair with screws across the first and third tarsometatarsal joints as well as an intercuneiform screw. Degenerative changes were noted at the Lisfranc joints, and there was assumption she had the second tarsometatarsal and Lisfranc fixation removed at her second surgery. On closer interpretation of the radiographs, the tarsometatarsal screws were cannulated and fully threaded typical for open reduction internal fixation (ORIF) hardware versus arthrodesis and the screw for the third metatarsal was slightly bent (Figure 9.1). She also had an increased intermetatarsal angle of 19° and a tibial sesamoid position of 7.
Because the first tarsometatarsal joint was short, no corrective osteotomy was utilized. Instead, the joint surfaces were prepared and the intermetatarsal angle was reduced with a clamp to the stable second. The joint was temporarily fixated and the medial osseous void then filled with bone allograft (Figure 9.3). This was then fixated with a screw and locking plate. Now that the first and second tarsometatarsal joints were reduced and fixated, the 2 rays were clamped to further reduce the first interspace, and a Lisfranc screw was placed (Figure 9.4). The position of hardware and reduction of deformity was confirmed and the patient was admitted for postoperative pain control.